Healthcare Provider Details

I. General information

NPI: 1447016795
Provider Name (Legal Business Name): ANNY PARK MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 RIVER GREEN PKWY STE 140
DULUTH GA
30096-8333
US

IV. Provider business mailing address

4855 RIVER GREEN PKWY STE 140
DULUTH GA
30096-8333
US

V. Phone/Fax

Practice location:
  • Phone: 678-417-0077
  • Fax: 678-417-0337
Mailing address:
  • Phone: 678-417-0077
  • Fax: 678-417-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN290211
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: